R E V I E W

The Osteocyte: An Endocrine Cell . . . and More

Sarah L. Dallas, Matthew Prideaux, and Lynda F. Bonewald

Department of Oral and Craniofacial Sciences, School of Dentistry, University of Missouri-Kansas City, Kansas City,
Missouri 64108

Few investigators think of bone as an endocrine gland, even after the discovery that osteocytes produce cir-

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culating fibroblast growth factor 23 that targets the kidney and potentially other organs. In fact, until the last
few years, osteocytes were perceived by many as passive, metabolically inactive cells. However, exciting recent
discoveries have shown that osteocytes encased within mineralized bone matrix are actually multifunctional
cells with many key regulatory roles in bone and mineral homeostasis. In addition to serving as endocrine cells
and regulators of phosphate homeostasis, these cells control bone remodeling through regulation of both
osteoclasts and osteoblasts, are mechanosensory cells that coordinate adaptive responses of the skeleton to
mechanical loading, and also serve as a manager of the bone’s reservoir of calcium. Osteocytes must survive for
decades within the bone matrix, making them one of the longest lived cells in the body. Viability and survival
are therefore extremely important to ensure optimal function of the osteocyte network. As we continue to
search for new therapeutics, in addition to the osteoclast and the osteoblast, the osteocyte should be considered
in new strategies to prevent and treat bone disease. (Endocrine Reviews 34: 658 – 690, 2013)

I. Introduction location embedded within mineralized bone matrix rather

II. Osteocyte Differentiation and Embedding
III. Morphology of Osteocytes, Their Dendrites, and La-
cunocanalicular System
IV. Osteocyte Selective Genes/Proteins and Their Potential
Functions
V. Tools for Studying Osteocytes
VI. Osteocyte Mechanosensation and Transduction
A. How osteocytes sense loading
B. How loading affects osteocyte signaling
VII. Osteocytes as Orchestrators of Bone Formation and
Resorption
VIII. Osteocyte Life, Death, and in Between
IX. Osteocytic Perilacunar Remodeling: An Old Concept
Rediscovered
X. The Osteocyte as an Endocrine Cell
XI. Crosstalk Between Osteocytes and Muscle Cells
XII. Role of Osteocytes in Disease
XIII. Summary and Perspective
I. Introduction
f the major cell types in bone, osteoblasts and oste-
O oclasts have been defined by their respective func-
tions of bone formation and bone resorption, but osteo-
cytes were defined primarily by their morphology and
ISSN Print 0163-769X ISSN Online 1945-7189
Printed in U.S.A.
Copyright © 2013 by The Endocrine Society
Received May 2, 2012. Accepted April 16, 2013.
First Published Online April 26, 2013
than by their function. This is because until the past decade
or so there has been a lack of clear understanding about the
properties of these cells and their important functions in
the skeleton. This perception persisted despite the fact that
osteocytes make up over 95% of the bone cells in the adult
skeleton, with this ratio increasing with age and with the
size of the bone.
Osteocytes reside in lacunae within the mineralized
bone matrix and send their dendritic processes (ranging
from 40 –100 per cell [1]) through tiny tunnels called
canaliculi to form the osteocyte lacunocanalicular net-
work (Figures 1 and 2), which connects to cells on the bone
surface and to the vasculature. A fluid, termed canalicular
or bone fluid, that is still not well characterized travels
through the lacunocanalicular space and bathes the os-
teocyte, thereby providing oxygen and nutrients to main-
tain the viability of the cell in this enclosed environment.
Early bone histologists hypothesized various functions
for osteocytes, but lacked the tools to test their hypotheses.
Today, with the use of transgenic technologies combined
Abbreviations: ASARM, acidic serine aspartate-rich MEPE-associated motif; DKK1, Dick-
kopf1-related protein 1; DMP1, Dentin matrix protein 1; ER-␣, estrogen receptor-␣; FAK,
focal adhesion kinase; FGF, fibroblast growth factor; FGFR, FGF receptor; GFP, green
fluorescent protein; kb, kilobase; LRP, low-density lipoprotein receptor-related protein;
MEPE, matrix extracellular phosphoglycoprotein; NO, nitric oxide; NOS, NO synthase;
1,25(OH)2D, 1,25-dihydroxyvitamin D; OPG, osteoprotegerin; PC1, polycystin 1; PGE2,
prostaglandin E2; PHEX, phosphate-regulating gene with homologies to endopeptidases
on the X chromosome; PKA, protein kinase A; PKD1, polycystic kidney disease 1; PTH1R,
PTH receptor type 1; RANK, receptor activator of nuclear factor ␬-B; RANKL, RANK ligand;
SFRP1, secreted frizzled-related protein 1; TRAP, tartrate-resistant acid phosphatase.

658 edrv.endojournals.org Endocrine Reviews, October 2013, 34(5):658 – 690 doi: 10.1210/er.2012-1026
doi: 10.1210/er.2012-1026 edrv.endojournals.org 659

Figure 1. teoblast and osteoclast function. Osteocytes

also act as mechanosensors to control adaptive
responses to mechanical loading of the skele-
ton, and they may be a key target cell for the
actions of PTH in bone. The osteocyte there-
fore appears to integrate hormonal and me-
chanical signals in the regulation of bone mass.
Because osteocytes reside in an enclosed en-
vironment for extended periods of time, which
can last up to decades, the viability of these cells
becomes critical for their function. Not only

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does the viable osteocyte regulate bone homeo-
stasis, but the dying or apoptotic osteocyte also
may play key regulatory roles in sending sig-
nals to initiate bone remodeling, particularly
when there is a need for bone repair. Au-
tophagy (the process of controlled “self diges-
tion” of the cell contents) also appears to be
necessary to sustain the cell within the enclosed
environment of the mineralized matrix.
Another exciting and unexpected recent dis-
covery is that osteocytes may function in an
endocrine manner to regulate phosphate ho-
meostasis through secretion into the circula-
tion of fibroblast growth factor 23 (FGF23).
When one thinks of an endocrine organ, tissues
such as the pituitary or adrenal glands come to
mind, but one would not normally ascribe this
function to bone. However, kidney, liver, and
heart have all been shown to have endocrine
Figure 1. The osteocyte. Schematic representation of an embedded osteocyte
located within its lacuna, illustrating its dendritic processes passing through the bone
functions, and now it appears that bone (and
matrix (gray shading) within narrow tunnels termed canaliculi. The osteocyte’s specifically the osteocyte network) can be
dendritic processes interconnect with other osteocytes as well as surface osteoblasts. added to this category. Criteria for designating
Note that some osteocyte processes may extend beyond the osteoblast layer to
an organ as an endocrine gland are that it must
potentially interact with cells in the marrow and that osteocyte dendrites are also in
intimate contact with the vasculature. The composition of the perilacunar matrix form a system that directly secretes hormones
immediately adjacent to the osteocyte (mauve shading) is different from that of the into the bloodstream to affect distant target
rest of the bone matrix (gray shading), which may influence the magnitude of organs and cells. Endocrine organs must also
mechanical strains perceived by the osteocyte.
be highly vascularized. Bone meets these crite-
ria because it is a highly vascular organ and the
with molecular and cell biology and state-of-the-art in- osteocyte lacunocanalicular network is in intimate con-
strumentation, dramatic advances have been made in nection with this vascular supply (Figures 1 and 2). The
identifying and understanding the functions of these pre- kidney produces factors such as erythropoietin, and the
viously overlooked bone cells. It is now clear that, far from liver produces IGF, both of which can be considered hor-
being a passive cell as it has been historically described in mone-like. Similarly, the circulating factors produced by
the literature, the osteocyte is a key cell that is indispens- osteocytes, such as FGF23 and sclerostin, should also be
able for the normal function of the skeleton. Although considered in this category.
osteocytes most likely do not play a major role in embry- In summary, there has been an explosion in research on
onic bone development and may only play a secondary the properties and functions of osteocytes over the past
role in growth and development postnatally, they appear few years, leading to many exciting discoveries and the
to play a critical role in bone homeostasis in the adult assignment of new functions to this intriguing cell. This
skeleton. Thus, the osteocyte plays multifunctional roles review aims to summarize the current state of knowledge
in orchestrating bone remodeling by regulating both os- of the osteocyte and to review its many functions, includ-
660 Dallas et al Osteocytes as Endocrine Cells Endocrine Reviews, October 2013, 34(5):658 – 690

Figure 2.

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Figure 2. Osteocyte morphology and interaction with the vasculature. A, Confocal fluorescence image of osteocytes in the cortex of an adult
mouse femur stained with Alexa Fluor 488 phalloidin, which stains the actin cytoskeleton of the cell. Note the highly dendritic morphology of the
osteocyte with many actin-positive dendrites extending from the cell in all directions. Note also the extensive dendritic interconnections between
adjacent osteocytes. B, Confocal fluorescence image of the osteocyte lacunocanalicular system in mouse cortical bone as revealed by the tracer
dye, procion red. This dye is dispersed throughout the lacunocanalicular system within only 5 minutes of iv injection, demonstrating the intimate
connection of the canalicular fluid with the circulation (as modified from Ref. 231). C, Scanning electron micrograph of an acid-etched resin-casted
mouse cortical bone specimen, revealing the 3-dimensional organization of the osteocyte lacunocanalicular system and its interaction with a blood
vessel (BV). Note the 2 osteocyte lacunae (OCY) and extensive canaliculi, which are intimately connected to the surface of the blood vessel. Also
note the extensive, interconnected canaliculi throughout the bone matrix.

ing its novel function as an endocrine cell. The review will
also discuss the implications for treatment of bone diseases
and future directions for research of this fascinating and
unique cell.
II. Osteocyte Differentiation and Embedding
It is well accepted that osteocytes are derived from osteo-
blasts, which in turn are derived from osteogenic precur-
sors residing in the bone marrow. The mature osteocyte
represents a terminally differentiated stage of the osteo-
blast lineage. However, the precise mechanisms by which
an osteoblast becomes embedded in bone matrix to begin
a new life as an osteocyte and the genetic and molecular
mechanisms that regulate the differentiation and matura-
tion of the osteocyte are still not fully understood (re-
viewed in Refs. 2– 4). Once an osteoblast stops actively
forming new bone matrix, it is thought to have one of three
potential fates. It can become a quiescent cell on the bone
surface, known as a lining cell (5), it can undergo pro-
grammed cell death via the process of apoptosis (5, 6), or
it can become embedded in its own osteoid and differen-
tiate into an osteocyte. Several different transitional stages
between osteoblasts and osteocytes have been reported in
the literature (7–10), based mainly on morphological ob-
servations (reviewed in Ref. 2). Figure 3 shows a schematic
representation of these transitional stages, compiled from
these various articles.
The embedding of an osteoblast to become an osteocyte
has been viewed as a passive process in which a subpop-
ulation of osteoblasts on the bone surface slows down
their matrix production relative to adjacent cells. These
osteoblasts then become “buried alive” under the matrix
produced by neighboring osteoblasts (2, 8, 11). However,
research from two different groups suggests that the em-
bedding mechanism may actually be an active and invasive
process in which matrix degradation is required for the
formation of the osteocyte lacuna and canaliculi (12, 13).
During the transition process, one would expect the
differentiating osteocytes to share many markers with
their osteoblast precursors, but also to express unique
marker genes that play key regulatory roles in altering
their morphology and function. Until recently, character-
izing the molecular and genetic changes that occur during
osteoblast to osteocyte differentiation was challenging
due to the lack of appropriate osteocyte cell lines and dif-
ficulties in isolating sufficient numbers of osteocytes from
tissue sources. However, within the past two decades,
more and more markers of the osteocyte have been iden-
tified (reviewed in Refs. 3, 14, and 15). Furthermore, the
generation of transgenic mouse lines in which green flu-
orescent protein (GFP) variants are selectively expressed in
osteoblasts and osteocytes (16 –18) and the use of pro-
teomic and gene array technologies (19 –21) have enabled
comparisons of gene and protein expression profiles be-
tween osteoblasts and osteocytes, which has provided
clues to help identify the key mediators of osteocyte dif-
ferentiation and function. The changes in gene expression
that represent a signature for transition toward an osteo-
cytic phenotype include down-regulation of type I colla-
doi: 10.1210/er.2012-1026 edrv.endojournals.org 661

Figure 3.

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Figure 3. Osteocyte differentiation. A, Schematic diagram depicting the transitional stages that occur as osteoblasts differentiate into mature osteocytes. During
this process, the volume of the cell body and the number of cell organelles decreases. 1 ⫽ preosteoblast; 2 ⫽ osteoblast; 3 ⫽ embedding osteoblast; 4 ⫽ osteoid
osteocyte; 5 ⫽ mineralizing osteocyte; 6 and 7 ⫽ mature osteocytes. B, Tetrachrome-stained section of an adult mouse tibia illustrating several of the osteoblast-
osteocyte transitional stages depicted schematically in panel A (bar ⫽ 25 ␮m). C, Table illustrating the relative temporal expression of various osteogenic markers
during the transition from osteoblast to osteocyte as depicted in panels A and B. Runt-related transcription factor 2 (RUNX2) directs early osteoblast
differentiation and is expressed in both preosteoblasts and osteoblasts. Osteocalcin (OCN) is expressed by mature osteoblasts and early osteocytes. E11 is the
earliest osteocyte marker to be expressed during differentiation but is not found in mature osteocytes in vivo. DMP1, CapG, and MEPE expression is observed in
mineralizing and mature osteocytes, whereas sclerostin expression is confined to mature osteocytes. ORP150 is also only found in mature osteocytes within the
hypoxic environment of the mineralized bone matrix.
662 Dallas et al Osteocytes as Endocrine Cells
gen and alkaline phosphatase and up-regulation of genes
including dentin matrix protein 1 (DMP1), E11/GP38/
podoplanin, fibroblast growth factor 23 (FGF23), matrix
extracellular phosphoglycoprotein (MEPE), and phos-
phate-regulating gene with homologies to endopeptidases
on the X chromosome (PHEX) (2, 22–25). Induction of
SOST, which encodes the protein sclerostin (26), indicates
differentiation to a mature osteocyte phenotype. Com-
pared to osteoblasts, osteocytes are also enriched in pro-
teins associated with resistance to hypoxia, such as
ORP150 (20), and proteins important in cytoskeletal
function, including destrin, CapG, Cdc42, and E11 (19 –
21, 27, 28). Osteocytes also show high expression of
CD44 (29) and neuropeptide Y (30). This diverse set of
genes has functions ranging from regulation of mineral-
ization (DMP1, SOST) to phosphate homeostasis (PHEX,
MEPE, FGF23) and cytoskeletal arrangement and/or
dendrite formation (E11, CD44, CapG, Cdc42, and
destrin). The specific functions of these osteocyte marker
proteins are discussed in more detail in Section IV.
Although considerable progress has been made in gen-
erating a list of osteocyte marker genes, it remains unclear
which of these are actually the key mediators that control
osteocyte differentiation. Notable among them is the
membrane-bound protein E11, which is expressed in early
osteocytes (22, 31) and has been shown to play a role in the
formation of dendrites in osteocytes (32), a critical step in
their differentiation. DMP1 may also play a role in osteo-
cyte differentiation because deletion of this gene in mice
leads to a delay in osteocyte maturation (33). Sclerostin
has also recently been implicated as a regulator of the
differentiation from late osteoblast to preosteocyte
through its regulation of PHEX and MEPE (34). Interest-
ingly, oxygen tension may also regulate the differentiation
of osteoblasts into osteocytes (35), suggesting that some of
the genes associated with resistance to hypoxia may play
a role in osteocyte differentiation. In addition, mineral-
ization of the extracellular matrix surrounding the osteo-
cyte has also been shown to induce osteocyte maturation,
both in vitro (36) and in vivo (37, 38).
The embedding of osteocytes does not seem to be a
random process. When viewed 3-dimensionally, osteo-
cytes appear to be regularly spaced within the bone matrix,
with approximately equal distances between adjacent os-
teocytes. It remains unclear what dictates this highly or-
dered 3-dimensional organization of the osteocyte net-
work. One interesting hypothesis comes from the work of
Marotti (39), who has proposed that newly formed os-
teocytes secrete an osteoblast inhibitory signal once their
dendrites have reached their maximal length. This inhibits
osteoid production of the nearest, most intimately con-
nected osteoblast, which then becomes buried in matrix
Endocrine Reviews, October 2013, 34(5):658 – 690
produced by its neighbors. Marotti’s theory is based entirely
on morphological observations, but nevertheless, it is an at-
tractive hypothesis that potentially explains the ordered
spacing of osteocytes in 3 dimensions. Our own studies using
live cell imaging techniques have suggested that the osteo-
cyte-embedding process is highly dynamic and that the em-
bedding cells repeatedly extend and retract their dendrites,
making transient connections with already embedded osteo-
cytes (4, 40, 41). This “sampling” of the local environment
through the use of “exploratory dendrites” may allow the
osteocyte to position itself with an appropriate spacing from
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other embedded osteocytes to maintain the ordered 3-dimen-
sional spacing of the osteocyte network.
Although the molecular and genetic mechanisms that
regulate osteocyte differentiation are slowly being unrav-
eled, there remain many unanswered questions. These in-
clude the question of whether every osteoblast has an
equal chance of becoming an osteocyte or whether there
are specific subpopulations of osteoblasts with predefined
fates. Aubin and colleagues (42, 43) have reported exten-
sively on the heterogeneity of surface osteoblasts in terms
of their gene and protein expression profiles. It therefore
seems plausible that there are specific subpopulations of
osteoblasts on the bone surface that are already committed
to becoming an osteocyte. Another unresolved issue is
whether the decision for an osteoblast to differentiate into
an osteocyte is a cell autonomous response or one that is
controlled through signaling to surface osteoblasts from
osteocytes that are already embedded. Imai et al (44) pro-
posed that osteocytes can recruit osteoblasts and stimulate
their differentiation by expressing osteoblast stimulating
factor-1 (OSF-1; also known as heparin-binding growth
associated molecule, HB-GAM). They postulated that
these osteoblasts then further differentiate into osteocytes,
thereby providing a new source of OSF-1 for the next cycle
of osteoblast recruitment.
The life span of the osteocyte is most likely determined
by rates of bone turnover, the process by which osteoclasts
resorb bone and osteoblasts replace the resorbed bone.
Osteocytes may have a half-life of decades if they are lo-
cated within a bone that has a slow turnover rate. An
important question is whether the differentiation into an
osteocyte is a “one-way trip,” ie, is it an irreversible pro-
cess or do osteocytes have the ability to dedifferentiate
back to an osteoblast or potentially give rise to other lin-
eages, such as adipocytes and chondrocytes? The fate of
osteocytes released by osteoclastic resorption is presently
unknown. Some of the osteocytes that are only partially
exposed by resorptive activity may be re-embedded when
new bone is formed after resorption (45). Resorption
could also potentially liberate the osteocyte, but there is
little clear evidence that osteocytes dedifferentiate back
doi: 10.1210/er.2012-1026
into the osteoblastic state (46). It seems most likely that the
osteocytes exposed during bone resorption die by apopto-
sis and/or become phagocytosed by osteoclasts, as has
been described in several reports (47– 49). With the avail-
ability of transgenic mouse models in which lineage-tar-
geted GFP variants are expressed in osteoblasts and os-
teocytes (16 –18) and the availability of transgenic tools
for gene deletion and manipulation of gene expression in
osteocytes (50, 51), it seems likely that the answers to some
of these unresolved questions will soon be known and that
we will gain deeper and deeper insight into the mecha-
nisms controlling osteocyte differentiation.
III. Morphology of Osteocytes, Their Dendrites,
and Lacunocanalicular System
Osteocytes are one of an elite group of cells within the
body, which also includes cementocytes and hypertrophic
chondrocytes, that are completely encased within a min-
eralized extracellular matrix. This presents significant
challenges with regard to communication with other cells
and access to sufficient nutrients and oxygen. However,
the osteocyte and its lacunocanalicular system are exqui-
sitely adapted for this role and have developed a unique
physiology to cope with the challenges of being “impris-
oned” within a mineralized matrix.
Unlike the molecular regulatory mechanisms, the mor-
phological changes that occur during the transition from
an osteoblast to an osteocyte have been well characterized
(2, 10, 11, 52, 53). During differentiation, osteoblast mor-
phology changes from a polygonal shape to a more stellate
shape. One of the first changes to take place in the em-
bedding cell is the formation and elongation of numerous
cellular projections, or dendritic processes, which are ex-
tended in a polarized manner toward the mineralizing
front. This is followed by dendrites extending toward the
vascular space or bone surface. These long, slender cyto-
plasmic processes radiate in all directions around the
cell body of the osteocyte, with the highest density per-
pendicular to the bone surface (Figure 2, A and B). Once
embedded, the osteocyte maintains this polarity in the di-
rectionality of its dendrites and the directionality of min-
eralization such that mineral deposition occurs on 1 side
of the embedding cell rather than equally all around it
(Figure 3B). We have previously proposed that the osteoid
osteocyte (ie, the cell that is in the process of transitioning
from osteoblast to osteocyte), is the cell that is primarily
responsible for mineralization as opposed to osteoblasts
on the bone surface (40, 54).
As the osteocyte embeds and further differentiates,
there is a reduction in cell volume of up to 70% (10). Upon
edrv.endojournals.org 663
mineralization of the osteoid, there are also changes to
osteocyte ultrastructure, such as a reduction in the endo-
plasmic reticulum and Golgi apparatus (55). In the past,
this has been interpreted to imply reduced protein syn-
thesis and metabolic activity of the osteocyte, leading to
the misconception that osteocytes are passive, inactive
cells and are of little importance during bone growth
and development. However, it is now clear, as empha-
sized throughout this review, that osteocytes are highly
active cells that play major roles in many key physio-
logical processes both within and beyond the bone
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microenvironment.
The transition from a plump polygonal osteoblast to a
stellate, highly dendritic osteocyte represents a profound
change, which presumably requires extensive reorganization
of cytoskeletal proteins. The characteristic polarization of
the osteoblast is lost (56), and this is accompanied by striking
changes in the expression and localization of actin-binding
proteins, such as fimbrin, filamin, and ␣-actinin, as shown by
Kamioka et al (57). These authors proposed that the orga-
nized expression of tubulin, vimentin, and actin in the cell
bodies and dendrites of osteocytes is important to establish
and maintain their unique dendritic morphology (58).
At first glance, the osteocyte may appear to be isolated
from neighboring osteocytes in the mineralized matrix and
from osteoblasts on the bone surface. However, these cells
show a high degree of interconnectivity. The cell body is
enclosed within a lacuna of 15–20 ␮m in diameter, and the
cell processes pass through the bone matrix through nar-
row canals called canaliculi, approximately 250 –300 nm
in diameter (Figures 1 and 2). Together, the osteocyte la-
cunae and canaliculi are referred to as the lacunocanalicu-
lar system. Numerous dendritic processes connect osteo-
cytes to other osteocytes and allow osteocytes near the
bone surface to be connected to osteoblasts and bone-
lining cells. This characteristic morphology allows for the
passage of nutrients and biochemical signals from one os-
teocyte to another, and through these interconnections,
the embedded osteocytes form a functional network (re-
viewed in Refs. 15, 59, and 60). This interconnectivity of
the osteocytes facilitates communication and helps main-
tain cell viability and is therefore essential for the normal
functioning of the osteocyte. Disruption of the network
can have negative consequences for bone health. To enable
osteocytes to communicate with one another, gap junc-
tions are present on the tips of the dendrites connecting
them (61). These are transmembrane channels that con-
nect the cytoplasm of adjacent cells and allow the cells to
exchange molecules of less than 1 kDa (62).
Intriguingly, the work of Kamioka et al (63) suggests
that some osteocyte cell processes extend beyond the os-
teoblast layer, establishing direct contact between the os-
664 Dallas et al Osteocytes as Endocrine Cells
teocyte network and the marrow space. Through these
dendrites there is the potential for direct signaling between
osteocytes and cells in the bone marrow compartment.
Our studies using live cell imaging approaches suggest
that osteocytes, particularly those that have recently
embedded, can extend and retract their dendritic pro-
cesses, not only toward other osteocytes and osteo-
blasts, but also into marrow spaces (64). This suggests
that osteocytes have the potential to make and break
contact with other cell types.
The morphology of the lacunocanalicular system can
be demonstrated using techniques such as scanning elec-
tron microscopy (EM) of plastic-embedded, acid-etched
bone samples (65) or injection of mice with dyes such as
the small molecular weight dye, procion red (65, 66) (Fig-
ure 2, B and C). These techniques reveal the intimate con-
nection of the osteocyte lacunocanalicular system with the
vasculature and illustrate an important property of the
lacunocanalicular system, namely that the canalicular
space between the osteocyte dendrite and the canalicular
wall is filled with circulating fluid, canalicular fluid, that
carries solutes to and from the osteocyte via the circula-
tion. Dye-injection studies have shown permeation of the
osteocyte canalicular space from the bloodstream within
only a few minutes after injection (66). Tracer studies have
shown that molecules of less than 40 kDa can readily reach
the lacunocanalicular system from the circulation but that
molecules as large as 440 kDa cannot (67). The upper
cutoff appears to be less than 70 kDa, and a filter of some
sort appears to exist between the vascular system and the
osteocyte lacunocanalicular system (68). As discussed in
Section VI, mechanical loading of bone results in the flow
of canalicular fluid around the osteocyte and its dendrites,
which may provide a key stimulus for mechanotransduc-
tion (reviewed in Refs. 14, 60, 68, and 69). It is thought
that the lacunar and canalicular spaces are not completely
open but are filled with proteoglycans that constitute the
glycocalyx of the cell (reviewed in Refs. 59 and 70). These
may function as a molecular sieve that allows the rapid
passage of smaller molecular mass molecules (eg, ⬍70
kDa) but much slower passage of larger molecules (66).
Interestingly, the morphology of the lacunocanalicular
system may not be permanent. Several studies suggest that
osteocytes can modify their microenvironment by depos-
iting and resorbing bone around their lacunae (71–75).
Furthermore, there is evidence that the number of canalic-
uli increases with age (13, 76). This suggests either that the
new bone formed in older animals produces osteocytes
with more canaliculi or that existing osteocytes can gen-
erate new dendrites after they have embedded, presumably
through a matrix degradative process (13). This adds an
interesting changing dimension to considerations of the
Endocrine Reviews, October 2013, 34(5):658 – 690
osteocyte’s relationship with its lacunocanalicular system.
Nevertheless, by developing such an intricate network of
lacunae and canaliculi and by adopting its unique mor-
phology with extensive dendritic connections, the osteo-
cyte has been able to overcome the challenges of living in
the hostile environment of the mineralized bone matrix.
IV. Osteocyte Selective Genes/Proteins and
Their Potential Functions
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Determining genetic markers for osteocytes has proven to
be difficult due to the relatively low number of known
osteocyte-specific genes. The recent characterization of
proteins such as E11, sclerostin, DMP1, and MEPE as
osteocyte markers has, however, enabled easier identifi-
cation of osteocytes as well as providing insight into the
functions of these cells.
The earliest marker known to be expressed by the dif-
ferentiating osteocyte is E11 (22, 31). In the adult mouse,
this marker is specifically expressed in osteocytes but not
osteoblasts (32). Peak expression is observed in the young
osteocytes, in comparison with the more mature cells
deeper in the mineralized bone matrix. Regulation of E11
is poorly understood; however, the transcription factors
SP1/3 (77) and AP1 (78) are known to modulate expres-
sion, and E11 is susceptible to post-translational degra-
dation by the calpain family of proteases (79). E11 is
known to bind to CD44 (80) and ezrin-radixin-moesin
complexes; therefore, these molecules may function to-
gether to regulate the formation of dendritic processes in
osteocytes, a critical step in their differentiation. Overex-
pression of E11 in vitro has been shown to induce dendrite
formation in an osteoblast-like cell line (81), and similar
cytoskeletal rearrangements were observed in keratino-
cytes, with relocalization of ezrin to cell surface projec-
tions (82). Furthermore, small interfering RNA-mediated
knockdown of E11 prevented the fluid flow-induced elon-
gation of the cell processes of MLO-Y4 osteocyte-like cells
(32). In addition to regulating dendrite elongation, bind-
ing of E11 to the ezrin-radixin-moesin complexes activates
the small GTPase RhoA, and this was shown to result in
increased motility of an epithelial cell line (83). In vivo,
E11 expression was found to be increased in osteocytes
after mechanical loading (32). Deletion of E11 in mice did
not significantly affect embryonic bone development;
however, the effects of E11 on postnatal bone formation
are unknown because these mice die soon after birth due
to respiratory failure (84).
Several members of the SIBLING (small, integrin-bind-
ing ligand, N-linked glycoprotein) family of proteins are
also highly expressed by osteocytes and are known to have
doi: 10.1210/er.2012-1026
important functions within the bone environment. DMP1
expression has been described in hypertrophic chondro-
cytes and osteoblasts during embryonic bone formation
(85); however, its expression is more restricted to osteo-
cytes during postnatal development (23). One of the main
functions of DMP1 is thought to be in the regulation of
mineralization, consistent with its pattern of expression
within the bone (87). Further evidence for this is provided
by Dmp1-null mice, which show hypophosphatemia and
highly elevated levels of FGF23, leading to a severe im-
pairment in mineralization and resulting in an osteoma-
lacic phenotype (65). In contrast to loss of function, the
gain of function effects of DMP1 in vivo are less clear. Lu
et al (33) showed no effect of overexpressing full-length
DMP1 in bone under control of the 3.6-kilobase (kb) type
I collagen promoter, although it did completely rescue the
phenotype when overexpressed on a Dmp1-null back-
ground. In contrast, Bhatia et al (88) reported increased
bone mineral density in transgenic mice that overex-
pressed DMP1 ubiquitously under control of the cytomeg-
alovirus promoter. However, in this model, one must take
into account the fact that the DMP1 is expressed ectopi-
cally in tissues in which it is not normally expressed.
DMP1 loss of function mutations in humans have been
associated with autosomal recessive forms of hypophos-
phatemic rickets (65). These findings provided the first
evidence that osteocytes may play a major role in the reg-
ulation of phosphate homeostasis. Interestingly, osteo-
cytes within the osteomalacic bone of Dmp1-null mice
maintained their expression of alkaline phosphatase, type
I collagen, osterix, and E11 and failed to express mature
osteocyte markers, such as sclerostin (65). These studies
indicated that osteocyte differentiation was arrested at an
early stage, therefore suggesting a key role for DMP1 in
osteocyte maturation. The effects of DMP1 in the regula-
tion of mineralization and osteocyte maturation appear to
be predominantly due to its role in the regulation of phos-
phate homeostasis because the mineralization defects and
the impairment in osteocyte maturation can be rescued by
restoration of normal phosphate homeostasis (38). These
studies also highlight the importance of phosphate regu-
lation in control of osteocyte differentiation.
Another protein that is highly expressed in osteocytes is
PHEX, which was found to be the target of the osteocyte-
specific antibody Mab OB7.3 used to isolate avian osteo-
cytes (89). Mutation of PHEX results in X-linked hy-
pophosphatemic rickets (90), and Phex is the mutated
gene in the Hyp mouse, which is also widely used as a
model of X-linked hypophosphatemic rickets (91). Al-
though the exact function of PHEX remains to be deter-
mined, like DMP1, it is known to play a role in phosphate
homeostasis and mineralization of the bone matrix.
edrv.endojournals.org 665
Mutations in Phex, such as in the Hyp mouse, or loss of
PHEX expression leads to increased levels of FGF23
through an unknown mechanism and this leads to subse-
quent hypophosphatemia. Interestingly, FGF23 is not
normally expressed at high levels in osteocytes in the
healthy state, but its expression in osteocytes is dramati-
cally up-regulated in both DMP1- and PHEX-associated
hypophosphatemic rickets (92). Moreover, osteocytes ap-
pear to be the main source of the elevated circulating levels
of FGF23 seen in these mouse models, giving support to
the notion that they act as endocrine cells.
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FGF23 expression can also be regulated by another SIB-
LING protein, MEPE, which is predominantly expressed
by osteocytes (25). MEPE is not believed to act on FGF23
directly but increases FGF23 levels via inhibition of PHEX
enzymatic activity (93). MEPE can be proteolytically
cleaved by cathepsin B or D to release the highly phos-
phorylated ASARM peptide fragment (94),which in ad-
dition to antagonizing PHEX, can also inhibit matrix min-
eralization by binding directly to hydroxyapatite (95, 96).
Evidence is growing that modulation of FGF23 expression
by osteocyte proteins is of crucial importance in maintain-
ing phosphate homeostasis, and the high levels of expres-
sion of all these proteins in osteocytes further confirms
that phosphate regulation is a vital function of these cells.
One of the most exciting osteocyte-specific proteins to
be discovered is sclerostin, the protein product of the
SOST gene (97, 98), which is expressed by mature osteo-
cytes (26, 99). Sclerostin is a negative regulator of bone
formation that antagonizes the Wnt/␤-catenin signaling
pathway by binding to the Wnt coreceptors, low-density
lipoprotein receptor-related proteins 5 and 6 (LRP5 and
LRP6) (100). When Wnt ligand binds to LRP5/6, the re-
ceptor is phosphorylated, resulting in the activation of
disheveled, which in turn represses glycogen synthase ki-
nase 3 (GSK3). This results in the release of axin from its
complex with ␤-catenin. The ␤-catenin accumulates and
translocates to the nucleus, where it binds to transcription
factors, leading to the activation of Wnt target gene ex-
pression (reviewed in Ref. 101). However, in the presence
of sclerostin, Wnt-receptor interaction is inhibited, and
␤-catenin is phosphorylated by glycogen synthase kinase
3 and targeted for ubiquitination and degradation via the
proteosome pathway. Studies using loss of function and
gain of function mouse models of Sost have demonstrated
increased and decreased bone mass, respectively (26, 102).
Sclerostin expression is decreased by mechanical loading
(103), and it was recently reported that the anabolic effects
of loading are dependent on this decrease in expression
(104). The profound gain of bone mass observed after the
deletion of Sost has led to the development of monoclonal
antibodies directed against sclerostin as a potential ana-
666 Dallas et al Osteocytes as Endocrine Cells
bolic treatment for osteoporosis. Animal studies and early
results from clinical trials look very promising and suggest
that such antibodies may be an effective therapeutic for
increasing bone mass (105–107).
Microarray comparisons of the gene expression pro-
files of ex vivo osteoblasts and osteocytes have been per-
formed to identify other osteocyte-expressed genes that
may play important roles in bone (21). Increased expres-
sion of genes associated with neurons, such as neuropep-
tide Y, was reported. Further studies have shown that os-
teocyte-expressed neuropeptide Y can inhibit osteoblast
activity and differentiation (30) and that neuropeptide Y
expression can be modulated by mechanical loading. Pro-
teomic studies have also been used to identify proteins
that are highly expressed by osteocytes. The expression
of ORP150, destrin, and macrophage-capping protein
(CapG) were found to be increased in MLO-Y4 cells com-
pared to MC3T3 preosteoblasts, and increased expression
was confirmed in osteocytes relative to osteoblasts in vivo
(20). Destrin and CapG are believed to play a role in den-
drite formation, whereas ORP150 is likely to protect the
cells from the hypoxic conditions encountered within the
mineralized bone matrix.
Figure 3C summarizes some of the main marker genes
that are differentially expressed during the transition from
an osteoblast to an early and late osteocyte and indicates
their temporal expression patterns. The further identifi-
cation of such genes is imperative to provide more genetic
markers for the osteocyte and to provide better tools for
defining the steps in the osteocyte differentiation pathway.
A greater understanding of the function of these genes is
essential to fully elucidate the key roles that the osteocyte
is playing, not only in the maintenance of bone mass, but
also during endocrine signaling.
V. Tools for Studying Osteocytes
Although osteocytes remain one of the more challenging
cells to study due to their inaccessible location within the
mineralized bone matrix, recent advances both in vivo and
in vitro have facilitated investigation into their function.
The development of the Dmp1-Cre mouse line, in which
Cre recombinase expression is driven by the 10-kb Dmp1
promoter, has enabled researchers to delete genes specif-
ically in Dmp1-expressing cells (50). The authors found
that Cre recombinase activity was predominantly con-
fined to osteocytes and odontoblasts with some activity in
a subpopulation of late surface osteoblasts in these mice.
Although only recently developed, these mice have already
been successfully used to investigate the functions of sev-
eral molecules in osteocytes, including ␤-catenin (108),
Endocrine Reviews, October 2013, 34(5):658 – 690
PTH receptor type 1 (PTH1R) (109), polycystin 1 (PC1)
(110), Mef2C (111), and receptor activator of nuclear fac-
tor ␬-B ligand (RANKL) (112, 113).
The Dmp1 promoter has also been used to drive ex-
pression of the diphtheria toxin receptor in osteocytes in
a murine transgenic model (51). This enabled the condi-
tional ablation of up to 80% of the osteocytes upon in-
jection of diphtheria toxin and has provided further in-
sight into the importance of these cells in processes such as
mechanotransduction and bone homeostasis, both of
which were severely disrupted after osteocyte ablation.
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Transgenic mice in which GFP is under control of the 8-kb
Dmp1 promoter have also been created and have provided
an elegant and valuable new tool for osteocyte research
(16). Calvarial cells from these mice were harvested, and
the GFP-positive osteocytes were isolated via fluores-
cence-activated cell sorting. The GFP-positive cells were
then used for gene expression analysis (21).
Before these sophisticated transgenic tools became
available, more traditional methods were used for isola-
tion of osteocytes, and such methods still remain impor-
tant research tools within the field. These methods include
the isolation of osteocytes from avian bone by sequential
EDTA and collagenase digestions and their purification
using the monoclonal antibody OB7.3 (114). Similar di-
gestion techniques have also been used on rat calvaria
(115, 116) and long bones (56) to achieve osteocyte-
enriched populations of cells. However, difficulties in ob-
taining substantial yields, in addition to maintaining the
osteocyte phenotype of the ex vivo cells, have limited the
usefulness of these techniques. A recently described
method has improved upon these techniques, enabling the
isolation of greater numbers of osteocytes from mature or
aged bone by grinding the bone fragments into a fine dust
(117), thereby releasing osteocytes from the mineralized
bone matrix.
Determination of osteocyte function in vitro has been
greatly facilitated by the creation of immortalized osteo-
cyte-like cell lines. Perhaps the best characterized of these
cell lines are the MLO-Y4 cells, which are representative
of an early osteocyte. These cells have been extensively
studied (118 –120) and their characteristics are outlined in
Table 1. However, although MLO-Y4 cells have proved to
be a very useful tool for studying osteocytes in vitro, they
cannot provide information on the temporal changes in
gene expression and morphology that occur as an osteo-
blast differentiates into an osteocyte. Primary calvarial
osteoblasts have been widely used to study terminal os-
teoblast differentiation (121, 122), but the removal of
these cells from the bone results in a highly heterogeneous
cell population and may also result in contamination with
fibroblasts and osteoclast precursors. Several osteoblastic
doi: 10.1210/er.2012-1026
Table 1. Characteristics of the Currently Described Osteocyte Cell Lines
Name Origin
HOB-01-C1 Human cancellous bone
MLO-Y4 C57Bl/6 mouse long bone
MLO-A5 C57Bl/6 mouse long bone
IDG-SW3 Long bone cells derived from the Immortomouse
crossed with the 8-kb-Dmp1-GFP mouse (16)
Abbreviation: IFN-␥, interferon-␥.
cell lines have been described that differentiate toward an
osteocyte-like phenotype in culture. These include HOB-
01-C1 preosteocyte cells (123), MLO-A5 late osteoblast
cells (124), and IDG-SW3 late osteoblast cells (125),
which synthesize and mineralize a type-I collagen extra-
cellular matrix and express known osteocyte markers.
More information on these cell lines is provided in Table
1. These in vitro models form important tools which,
alongside in vivo models, are essential for further inves-
tigation into osteocyte differentiation and function.
VI. Osteocyte Mechanosensation
and Transduction
Two of the earliest functions ascribed to osteocytes were
mechanosensation and mechanotransduction. It was first
recognized by Julius Wolff that bone has the capacity to
adapt to mechanical loading or lack of loading by adding
or removing bone, thereby modifying bone mass (126).
Because of the distribution of osteocytes throughout the
bone matrix and their complex interconnected network,
early investigators hypothesized that they are the cells re-
sponsible for sensing mechanical loading or lack of load-
ing. By performing targeted deletion of osteocytes in mice
expressing the diphtheria toxin receptor specifically in os-
teocytes, it was shown that these mice were resistant to
edrv.endojournals.org 667
Characteristics
Infected with temperature-sensitive large T antigen, cells proliferate at 34°C but
do not divide at 40°C
Preosteocyte-like phenotype; express low levels of alkaline phosphatase and high
levels of osteocalcin
Synthesize a mineralized matrix (123)
Express SV40 large T antigen driven by osteocalcin-promoter
Immature osteocyte-like phenotype with dendritic morphology
Low alkaline phosphatase and high osteocalcin expression (120)
Express high levels of the early osteocyte marker E11 (32) but low levels of the
mature osteocyte marker Sost (184, 212)
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Respond to fluid flow by activating Wnt/␤-catenin signaling (131) and opening
Cx43 hemichannels (163)
Support osteoclast formation and activation in co-culture systems (116) and form
gap junctions with MC3T3-E1 cells (304)
Express primary cilia (137)
Express SV40 large T antigen driven by the osteocalcin promoter
Late osteoblast phenotype and differentiate toward an osteocyte-like phenotype
Synthesize a mineralized matrix, which has a composition similar to normal bone
(124) and is comprised of calcospherulites deposited along collagen fibrils (54)
Express Sost (212), Dmp1, Phex, and Cd44 (36)
IFN-␥ and temperature-sensitive SV40 large T antigen, induces proliferation at
33°C with IFN-␥ but not at 37°C
Synthesize a mineralized matrix
Express GFP under control of the 8-kb Dmp1 promoter
Temporally express early and late osteocyte markers such as E11, Dmp1, Phex,
Mepe, Sost, and Fgf23 (125)
unloading-induced bone loss (51). These findings further
support the hypothesis that osteocytes are key mechano-
transducers in bone.
A. How osteocytes sense loading
When a bone is mechanically loaded, there are several
possible stimuli that could be detected by the mechano-
sensory osteocyte. These include the physical deformation
of the bone matrix itself, the load-induced flow of cana-
licular fluid through the lacunocanalicular network,
which results in fluid flow shear stress, or electrical stream-
ing potentials that are generated from the flow of the can-
alicular fluid (which is an ionic solution) past the charged
surfaces of the lacunocanalicular walls and/or cell mem-
brane. The osteocyte and its dendritic processes are con-
stantly exposed to canalicular fluid that flows through the
lacunocanalicular system. It has been proposed that a
baseline flow of canalicular fluid is driven by the extravas-
cular pressure, but that on top of this are superimposed
rapid alterations in canalicular fluid flow that occur as a
result of intermittent mechanical loading of the bone
(127). This results in the cells being exposed to fluid flow
shear stress. In vivo, it is difficult to separate out the 3 types
of stimuli because any mechanical loading input will result
in the osteocyte being exposed to all three stimuli, includ-
ing deformation of the bone matrix, fluid flow shear stress
668 Dallas et al Osteocytes as Endocrine Cells
due to changes in canalicular fluid flow, and associated
streaming potentials.
Almost every cell responds to mechanical loading; how-
ever, osteocytes appear to be one of the most sensitive cell
types. Osteocytes are more sensitive than osteoblasts and
fibroblasts to applied loading in the form of fluid flow
shear stress and are more sensitive to fluid flow shear stress
than to substrate stretching (128, 129). Theoretical mod-
els have been used to predict the fluid flow shear stresses
exerted on osteocyte dendrites as a result of peak physi-
ological loads in vivo and have estimated these to be in the
range of 8 to 30 dynes/cm2 (127). Recently, real-time mea-
surement of load-induced solute transport has been per-
formed, and these studies suggested a peak shear stress of
5 Pa (approximately 30 dynes/cm2) (130). MLO-Y4 os-
teocyte-like cells are several orders of magnitude more
sensitive to fluid flow shear stress than 2T3 osteoblast-like
cells (131) and MC3T3 osteoblast cells (132, 133).
There has been considerable debate within the field as
to which part of the osteocyte is most important in sensing
mechanical strain. Some investigators have proposed that
the osteocyte only senses mechanical load through its den-
dritic processes and that the osteocyte cell body is rela-
tively insensitive to mechanical strain (134, 135). Others
have proposed that osteocytes sense strain through both
the cell body and dendritic processes (136), or that the
primary cilium, a single hair-like projection found on ev-
ery cell, is the primary strain-sensing mechanism in the
osteocyte (137, 138). There appears to be evidence for all
three mechanisms, and it remains unclear whether the cell
body, cell processes, and cilia work separately or in con-
junction to sense and transmit mechanical stimuli. Recent
studies using MLO-Y4 cells loaded by fluid flow shear
stress on their dendrites or cell bodies suggest that the
glycocalyx, present on the surface of dendritic processes,
but not the cell body, plays an essential role in mechano-
transduction by dendrites (139).
Removing the single primary cilium on either MC3T3
osteoblast or MLO-Y4 osteocyte cells by gene silencing
approaches or using treatment with chloral hydrate re-
duced the amount of prostaglandin released by MLO-Y4
cells in response to fluid flow shear stress and also reduced
increases in cyclooxygenase 2 and the osteoprotegerin
(OPG)/RANKL ratio (138). The primary cilia in bone cells
do not appear to mediate calcium flux in response to fluid
flow; therefore, the mechanism used by primary cilia in
bone cells is distinct from that of kidney cells (138). Re-
cently, it has been shown that primary cilia signal through
cAMP and adenyl cyclase 6 (140) and can mediate signal-
ing between osteocytes and mesenchymal stem cells (141).
It is well known that polycystin 1 (PC1), encoded by the
gene PKD1, is part of a mechanosensing complex in renal
Endocrine Reviews, October 2013, 34(5):658 – 690
cells that is associated with the primary cilium. Interest-
ingly, mice with impaired PC1 function develop osteope-
nia (137), and deletion of PKD1 in osteocytes using the
10-kb Dmp1-Cre driver results in reduced bone mass in
the young skeleton, which subsequently recovers in the
adult skeleton. However, these adult mice are less respon-
sive to anabolic load (110). The effects of deleting PC1 are
reversed by deleting KIF3A, a transport protein known to
play a role in the function of cilia (142).
Adhesion molecules are proposed to anchor the osteo-
cyte cell body to the lacunar wall and the dendritic pro-
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cesses to the canalicular wall and to potentially interact
with cytoskeletal proteins. These proteins therefore may
play important roles in mechanotransduction. CD44,
which is highly expressed on the osteocyte surface, was the
first adhesion receptor to be described on osteocytes
(29). The actin-bundling protein fimbrin is expressed at
branches of dendritic processes (58). Both are known to
connect to, and influence, the cell cytoskeleton. Integrins
are well known to serve as major receptors/transducers
connecting the cytoskeleton to the extracellular matrix in
many cell types (143). It has been proposed that integrins
bridge osteocyte processes to their canalicular wall and
that they may play an important role in amplifying the
strains perceived by osteocyte dendrites as a result of fluid
flow (144). Recently, it was found that integrin ␣5␤1 in-
teracts with Cx43 to mediate the opening of hemichannels
in MLO-Y4 cells in response to mechanical stimulation.
Surprisingly, this interaction appeared to be independent
of the integrin association with fibronectin and its inter-
action with the extracellular matrix (145). This interac-
tion between integrin ␣5 and Cx43 is important in the
regulation and extracellular release of prostaglandin, an
essential transducer of the effects of anabolic loading.
Therefore, fluid flow shear stress may have 2 major effects
on the osteocyte that are mediated through integrins; the
first is the well-known effect of the integrin acting as a
linker between the extracellular matrix and the intracel-
lular cytoskeleton; and the second, novel effect is through
the opening of hemichannels that can release small mol-
ecules with autocrine and paracrine receptor-mediated
effects.
It has been shown that the osteocyte lacuna itself acts as
a strain concentrator that amplifies the macroscopic strain
applied over the whole bone. This strain amplification is
strongly affected by the tissue material properties of the
local perilacunar matrix immediately surrounding the os-
teocyte lacuna (136, 146, 147). Using a microstructural
finite element analysis model, these investigators further
showed that changes in the modulus of the osteocyte cell
body and dendritic processes had little effect on the max-
imum strain transmitted to the osteocyte, the average
doi: 10.1210/er.2012-1026
strain in the cell processes, or the maximum strain in the
lacuna. In contrast, changing the material properties of the
perilacunar matrix had the greatest impact on the strain
transmitted to the osteocyte, with the maximum osteocyte
strain relating inversely to the perilacunar tissue modulus.
Therefore, any mechanism that changes the material prop-
erties of the perilacunar matrix, such as glucocorticoid-
induced hypomineralization (75), will have significant
consequences to mechanosensation by osteocytes.
B. How loading affects osteocyte signaling
A true mechanotransducer must be able to convert the
perceived mechanical strain signal into a biological output
(ie, a cellular response). Although the precise biochemical
pathways have yet to be fully unraveled, considerable
progress has been made toward delineating some of the
response pathways in osteocytes that may mediate adap-
tive responses to mechanical loading and unloading in
bone. In both primary osteocytes and MLO-Y4 osteocyte-
like cells, fluid flow shear stress increases intracellular cal-
cium; promotes the release of nitric oxide (NO), ATP, and
prostaglandins; induces opening of connexin 43 hemi-
channels; and enhances gap junction functions. It has also
been shown to induce bending of cilia and to initiate sig-
naling pathways such as the Wnt/␤-catenin and protein
kinase A (PKA) pathways. Fluid flow shear stress also
protects osteocytes against apoptosis, activates gene tran-
scription and translation, and promotes dendrite elonga-
tion. It is still not clear what type of fluid flow shear stress
occurs physiologically within the lacunocanalicular sys-
tem, ie, whether it is steady, pulsatile, oscillatory, or a
combination of one or more of these. The magnitude, fre-
quency, and duration of the fluid flow stimulus in physi-
ological conditions are also still unclear.
With regard to the temporal sequence of osteocyte re-
sponses to mechanical loading, one of the earliest events to
occur in response to mechanical stimulation is the increase
in intracellular calcium. Voltage-operated calcium chan-
nels that can be regulated by hormones were shown to be
expressed in osteoblasts and osteocytes (148, 149). Ex-
pression of voltage-gated potassium (K⫹) channels during
the differentiation from osteoblasts to osteocytes leads to
different K⫹ currents during osteoblast to osteocyte tran-
sition (150). Because of their contribution to maintenance
of the cell membrane potential and their fast response
within 20 milliseconds, K⫹ channels and other ion chan-
nels may be involved in the earliest initiation of the
mechanical response in osteocytes. The T-type voltage-
sensitive calcium channel is more highly expressed in os-
teocytes compared to the L-type channel, which is more
highly expressed in osteoblasts (151). The T-type channel
edrv.endojournals.org 669
therefore may play a role in the unique kinetics of calcium
signaling in osteocytes (133).
Soon after this rapid change in calcium signaling,
within seconds to minutes, NO, ATP, and prostaglandin
are released. Deleting or inhibiting any one of these three
early small molecules will inhibit bone’s anabolic response
to loading (152–156). One of the earliest molecules re-
leased in response to shear stress is NO, which appears to
correlate with prostaglandin E2 (PGE2) release from os-
teocytes (128). In bone, NO inhibits resorption and pro-
motes bone formation. Both osteoblasts and osteocytes
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release NO in response to mechanical strain or fluid flow
shear stress (157). NO may also reduce osteocyte apopto-
sis (158, 159).
ATP is also rapidly released from osteocytes in response
to extracellular calcium or mechanical stimulation (160,
161). There is evidence that this occurs through functional
“hemichannels” that are formed by Cx43 on unopposed
osteocyte cell membranes. The opening of these hemichan-
nels by mechanical loading appears to provide a mecha-
nism for ATP and NAD⫹ release (162, 163). The P2X7
nucleotide receptor, an ATP-gated ion channel, may also
play a role because its deletion in mice resulted in a 70%
reduction in bone anabolic response to applied mechani-
cal loading, and fluid flow shear stress did not induce
prostaglandin release in cells isolated from these mice
(155). Blockers of P2X7 receptors suppressed prostaglan-
din release, whereas agonists enhanced release in bone
cells, suggesting that the P2X7 receptor is necessary for
release of prostaglandin in response to mechanical load.
Prostaglandins may be one of the key effectors of load-
related osteogenic responses. Treatment with prostaglan-
dins in vivo enhances new bone formation in response to
mechanical load (165), and inhibitors of prostaglandin
production, such as indomethacin, block the effects of
anabolic loading (152, 166). Fluid flow-induced shear
stress stimulates the rapid release of PGE2 by osteocytes
(163). Interestingly, these authors have shown that PGE2
is likely released through Cx43 hemichannels, which serve
as a portal for the exit of intracellular PGE2 in osteocytes
stimulated with fluid flow shear stress. This released PGE2
then signals in an autocrine/paracrine manner to the os-
teocytes to enhance gap junction function and increase
Cx43 expression. It remains to be confirmed whether
PGE2 release via Cx43 hemichannels is important for in
vivo load-related responses. So far, in vivo loss of func-
tion studies suggest that the in vivo role of Cx43 is
complex. Cx43 deficiency can either inhibit or enhance
the bone anabolic response to loading (167, 168), and
it has been suggested that the specific promoter used to
delete Cx43 at different stages of the osteoblast lineage
670 Dallas et al Osteocytes as Endocrine Cells
can affect not only the bone phenotype, but also the
responses to loading (169).
As would be surmised, numerous signaling pathways
are activated by mechanical loading of osteocytes. One of
the most important appears to be the Wnt/␤-catenin path-
way, important for osteoblast differentiation, prolifera-
tion, and matrix production. In osteocytes, this pathway
plays a role in transmitting signals of mechanical loading
from osteocytes to cells on the bone surface (reviewed in
Ref. 14). Interestingly, it has been shown that PGE2 re-
leased by mechanical loading acts through the ␤-catenin
pathway to enhance Cx43 expression and gap junction
function (170) and to protect osteocytes from glucocor-
ticoid-induced apoptosis (171).
Deletion of various components of the Wnt/␤-catenin
pathway has effects on bone responses to loading and un-
loading. In vivo, deletion of LRP5, a major coreceptor for
Wnt signaling, resulted in mice that showed impaired os-
teogenic responses to anabolic loading (172). Negative
regulators of the Wnt/␤-catenin pathway such as Dick-
kopf1-related protein 1 (DKK1) and sclerostin are highly
expressed in osteocytes (99). Sclerostin is expressed in the
mature osteocytes, and mechanical loading has been
shown to reduce sclerostin levels in bone (103), whereas
hind limb unloading increases sclerostin expression (173).
It has also been suggested that sclerostin must be down-
regulated in order for the osteogenic response to anabolic
loading to occur (104). Down-regulation of DKK1 and
sclerostin may create a permissive environment in which
Wnt proteins that are already present can activate the Wnt/
␤-catenin pathway. Whereas targeted deletion of
␤-catenin using the Dmp1-Cre driver results in dramatic
bone loss (108), deletion of only 1 allele results in mice
with a normal skeleton but a completely abrogated re-
sponse to anabolic loading (174). Taking all these studies
together, it appears that ␤-catenin plays an important role
not only in osteocyte gap junction function and commu-
nication, osteocyte viability, and bone integrity, but also in
bone responses to loading.
Other signaling pathways are activated in response to
mechanical loading and may also cross talk with the Wnt/
␤-catenin signaling pathway. Mice lacking the estrogen
receptor-␣ (ER-␣) isoform exhibit a defective response to
loading (175). Lanyon and co-workers (176) suggest that
the ER-␣ may play a role in shuttling ␤-catenin into the
nucleus in response to mechanical strain in osteoblasts.
This may in part explain how estrogen regulates bone mass
via a functional intersection of the estrogen signaling path-
way with Wnt/␤-catenin signaling through ER-␣.
Other genes known to be regulated by loading and by
unloading include E11, a marker for the early osteocyte.
This was shown to be up-regulated in response to me-
Endocrine Reviews, October 2013, 34(5):658 – 690
chanical loading (32), as are regulators of mineralization
and phosphate homeostasis such as PHEX, MEPE, and
DMP1 (177–179). As mentioned previously, Sost/scleros-
tin, a marker for the late osteocyte and an inhibitor of
osteoblast function, is down-regulated by anabolic me-
chanical loading and is increased in response to hind limb
unloading (103, 173). Recently, it has been shown that
unloading increases RANKL expression in osteocytes
(113), which may be responsible for the bone loss associ-
ated with unloading. It would follow that genes involved
in bone formation would be up-regulated in response to
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anabolic load and vice versa for unloading. Ideally, it
would be important to identify genes that are rapidly ac-
tivated in response to anabolic load to deduce the earliest
pathways activated by mechanical loading.
Overall, there is considerable evidence that osteocytes
play key roles in mechanosensation and mechanotrans-
duction in bone, and whereas some of the pathways and
regulatory mechanisms are beginning to be elucidated,
there is still much that remains to be determined. A com-
plete understanding of these pathways may lead to excit-
ing opportunities for bone anabolic therapeutics because
a drug that could mimic the effects of mechanical loading
or amplify bone anabolic responses to loading would be a
valuable therapeutic for diseases such as osteoporosis.
VII. Osteocytes as Orchestrators of Bone
Formation and Resorption
A key feature of osteocytes is their ability to regulate the
function of both osteoblasts and osteoclasts. It is therefore
becoming clear that in contrast to the historical view of
osteocytes as passive cells, they may actually function as
central orchestrators of bone remodeling that can inte-
grate both hormonal and mechanical signals to regulate
bone mass. This type of mechanism makes sense because
through the osteocyte’s centralized role in regulating re-
sponses to these stimuli, the skeleton would be able to meet
not only the demands of its mechanical environment but
also its other demands in relation to calcium and phos-
phate homeostasis.
The lacunocanalicular system is the ideal network for
enabling the transmission of biochemical signals from
deeply embedded osteocytes to osteoblasts at the bone
surface and thereby allowing osteocytes to influence os-
teoblast activity. Indeed, in vitro studies have shown that
avian osteocytes (180) and MLO-Y4 cells (181) release
factors that enhance osteoblast differentiation and alka-
line phosphatase activity. Osteocytes have also been
shown to induce new bone formation at sites of fracture
damage by recruiting mesenchymal stem cells via the se-
doi: 10.1210/er.2012-1026
cretion of osteopontin (182). However, much is still to be
learned about the mechanisms by which osteocytes signal
to osteoblasts.
As discussed earlier, signaling molecules such as NO,
PGE2, and ATP are known to be rapidly released by os-
teocytes in response to external stimuli such as mechanical
strain, and many of these have direct effects on osteoblasts.
NO generation by endothelial NO synthase (NOS) is be-
lieved to be the main source of NO from osteocytes (183),
although the inducible form of NOS has been detected in
osteocytes after mechanical loading (153, 185). Neural
NOS was also detected in human osteocytes (186). NO
released by osteocytes in vivo has been shown to be im-
portant for bone formation during reloading (153), and in
vitro, osteocyte-derived NO inhibits proliferation of early
osteoblasts and promotes osteoblast differentiation (180).
The effects of PGE2 on osteoblasts and its anabolic effects
on bone have also been extensively documented (see Ref.
187 for review). PGE2 is known to induce bone formation
(188) and osteoblastic differentiation of primary calvarial
cell cultures in vitro (189) and to increase overall bone
mass in vivo (190, 191). As discussed in Section VI, os-
teogenic responses to mechanical loading are impaired if
production of prostaglandins is inhibited and are en-
hanced by treatment with PGE2.
One of the most important signaling pathways used by
osteocytes to regulate bone formation is the Wnt/␤-
catenin pathway. Osteocytes express several modulators
of Wnt signaling and therefore may regulate osteoblast
activity via this mechanism. The activation of canonical
Wnt signaling in early osteoblasts promotes osteoblast dif-
ferentiation and bone formation (192) with opposing ef-
fects observed when Wnt signaling is disrupted (193). Sev-
eral osteocyte-secreted Wnt antagonists have been
described, with sclerostin in particular being the focus of
many recent studies. In addition to sclerostin, osteocytes
express the LRP5/6 inhibitor DKK1, which inhibits os-
teoblast differentiation and bone formation (194 –196).
Similar to sclerostin, DKK1 expression is down-regulated
by mechanical loading in vivo (103), leading to enhanced
bone formation. Another Wnt pathway inhibitor ex-
pressed by osteocytes is secreted frizzled-related protein 1
(SFRP1), which is a competitive antagonist of Wnt ligand
binding. Loss of SFPR1 expression in vivo results in in-
creased bone mass and mineral density and in vitro en-
hances osteoblast proliferation and differentiation into os-
teocytes (197). Peak SFRP1 expression is observed in the
immature osteocyte and was decreased in the mature cell,
indicating a role for SFRP1 in the negative regulation of
cell survival during matrix embedding (198).
The control of bone remodeling requires regulation of
not only osteoblast but also osteoclast activity. Coculture
edrv.endojournals.org 671
studies performed on both MLO-Y4 cells (116) and pri-
mary chick osteocytes (199) show that osteocytes are po-
tent supporters of osteoclast formation and activation in
vitro. In the study by Zhao et al (116), as few as 50
MLO-Y4 cells per well were required to promote robust
osteoclast formation even in the absence of osteotropic
factors. Osteoclast precursors express receptor activator
of nuclear factor ␬-B (RANK) on their cell surface. This
receptor binds to its ligand, RANKL, which is expressed
on the surface of cells of the osteoblast lineage, and it is this
binding interaction between RANK and RANKL that pro-
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motes the differentiation of osteoclast precursors to form
mature osteoclasts. Importantly, RANKL expression has
been detected in osteocytes in vivo (200, 201) and
MLO-Y4 cells in vitro (116, 202, 203), consistent with
their ability to support osteoclast formation. Osteocytes
and MLO-Y4 cells are also known to express another fac-
tor required for osteoclast activation, macrophage-colony
stimulating factor, in addition to OPG, a decoy receptor
for RANKL (116, 204). Deletion of ␤-catenin in osteo-
cytes using Dmp1-Cre resulted in decreased expression of
OPG and a subsequent increase in the RANKL/OPG ratio
(108). These mice were characterized by severe osteopo-
rosis, which was a consequence of enhanced osteoclast
activity and excessive bone resorption. The importance of
osteocytes in regulating osteoclastic activity was recently
confirmed in elegant in vivo studies performed by Xiong
et al (113) and Nakashima et al (112) in which RANKL
was deleted specifically in osteocytes. These mouse models
developed an osteopetrotic phenotype, which led the au-
thors to conclude that osteocyte-derived RANKL is essen-
tial for normal bone remodeling in adult mice (112, 113).
Therefore, there is a fairly strong body of evidence that
Wnt signaling in osteocytes, via regulation of RANKL/
OPG, acts as a negative regulator of bone resorption.
Osteocyte death via apoptosis is also thought to result
in local bone remodeling via the recruitment of osteoclasts
to sites of bone damage. Viable osteocytes have been pro-
posed to secrete as yet unknown factor(s) that inhibit os-
teoclast activity, and a loss of production of these factors
due to osteocyte death may release the osteoclasts from
inhibition (205). Consistent with this hypothesis, the tar-
geted in vivo ablation of osteocytes using the osteocyte-
specific diphtheria toxin receptor mouse model was
shown to induce osteoclast formation and activation,
leading to bone loss (51). Additionally, targeted damage of
MLO-Y4 cells cultured in a 3-dimensional collagen gel
induced osteoclast formation specifically at sites of injury
(206) and apoptotic MLO-Y4 cells release HMGB1 (high
mobility group box 1), which is chemotactic to osteoclasts
(207). Osteocyte-derived apoptotic bodies have also been
shown to induce osteoclast formation in vitro and in vivo,
672 Dallas et al Osteocytes as Endocrine Cells Endocrine Reviews, October 2013, 34(5):658 – 690

Figure 4. this mouse model, but the net result

was an increase in bone mass. Con-
versely, in a lactating mouse model
in which there is a chronic elevation
in PTHrP, RANKL was shown to be
elevated in osteocytes (215) and
most likely to be responsible for in-
creased osteoclast activity.
Overall, it is becoming clear that it
is not just the osteoblasts and oste-
oclasts that are the critical players in

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bone remodeling, but that the osteo-
cyte also plays a key role in regulat-
ing the activity of these two cell
types, as summarized in Figure 4.
Moreover, the osteocyte appears to
Figure 4. Osteocyte regulation of bone remodeling. Osteocytes express RANKL and macrophage- be playing a centralized role in inte-
colony stimulating factor (M-CSF) to promote, and OPG and NO to inhibit, osteoclast formation grating mechanical loading and hor-
and activity. Osteocytes also regulate bone formation via the secretion of modulators of the Wnt
signaling pathway. PGE2, NO, and ATP act to activate Wnt signaling, whereas sclerostin, DKK1, monal signals to regulate bone mass
and SFRP1 all inhibit Wnt signaling and subsequent osteoblast activity. Maintenance of this in the skeleton.
balance between resorption and formation by the osteocyte is essential for bone homeostasis.

whereas osteoblast-derived apoptotic bodies had no effect
(208). This effect was not mediated by RANKL but was
shown to be TNF-␣-dependent.
As mentioned above, NO signaling can influence bone
mass by increasing bone formation; however, it is also
known to inhibit osteoclasts. Conditioned media from me-
chanically stimulated chick osteocytes inhibited osteoclast
formation and bone resorption in vitro, whereas this effect
was blocked upon the addition of an NOS inhibitor (209).
Osteocyte production of NO therefore appears to pro-
mote bone formation while at the same time inhibiting
bone resorption.
In addition to their role in mediating adaptive responses
to mechanical loading, osteocytes can also respond to hor-
monal signals to affect bone formation and resorption.
The presence of the PTH receptor (PTH1R) has been de-
tected on the surface of osteocytes as well as osteoblasts
(210, 211). Signaling by PTH and PTHrP is known to have
either anabolic or catabolic effects on the skeleton, de-
pending on whether the administration is intermittent or
continuous. It now appears that osteocytes may be a key
target cell for the anabolic actions of PTH in the skeleton
because these anabolic effects have been shown to be due,
at least partly, to down-regulation of osteocyte Sost ex-
pression (212, 213). Constitutive activation of the PTH1R
in osteocytes in vivo, under control of the Dmp1 pro-
moter, also inhibits Sost expression and dramatically in-
creases bone formation. This phenotype is dependent on
increased Wnt signaling (214). Interestingly, increased os-
teoclast activity and bone turnover were also observed in
VIII. Osteocyte Life, Death, and in Between
Not only the healthy, viable osteocyte, but also the dying
or dead osteocyte can have important regulatory effects on
other cell types in bone. Whereas some osteocytes appear
to sacrifice themselves by apoptosis to initiate bone re-
modeling or bone resorption, others remain viable in the
bone matrix until the death of the organism. Unlike oste-
oclasts that only live for days and osteoblasts that live for
weeks, osteocytes are an extremely long-lived cell, surviv-
ing for up to decades in bone matrix in adults. The life span
of the osteocyte is most likely determined by rates of bone
turnover, the process by which osteoclasts resorb bone
and osteoblasts replace the resorbed bone. Osteocytes may
have a half-life of decades if they are located within a bone
that has a slow turnover rate. The cell is nonmitotic while
it is encased in bone and appears to have developed pro-
tective mechanisms to ensure its survival, especially under
stress conditions such as immobilization, hypoxia, and
certain disease conditions. The osteocyte can undergo ne-
crosis, apoptosis, and autophagy, each of which may have
specific regulatory effects on other cells in bone. With age,
the dying osteocyte appears to undergo a process called
micropetrosis, in which the lacuna fills with mineral. Each
of these states most likely has a significant impact on the
canalicular fluid circulation within the lacunocanalicular
network, and on osteocyte cell functions such as mecha-
nosensation, signaling, and release of soluble mediators.
Damaged bone requires replacement. It was proposed
that microcracks that occur in bone can damage the os-
doi: 10.1210/er.2012-1026
teocyte and its processes, thereby inducing the cell to send
signals of osteoclast recruitment to initiate bone removal
and repair. Microdamage and bone fatigue are associated
with loss of osteocyte integrity (216). Verbogt et al (217)
have also shown that the antiapoptotic factor, B-cell lym-
phoma 2 (BCL-2), is found in osteocytes around the cut-
ting cone, whereas the proapoptotic factor, BCL-2-asso-
ciated X protein, is found in osteocytes in the path of the
osteoclast within the cutting cone, suggesting that these
osteocytes are undergoing programmed cell death. They
therefore proposed that the dying (apoptotic) osteocytes
were sending factors to recruit and direct osteoclasts to
remove the damaged bone. More recently, however, it has
been shown that the highest expression of osteoclast sup-
portive signals is found in a subpopulation of osteocytes
surrounding areas of microdamage. These osteocytes have
a higher RANKL/OPG ratio than that observed in apo-
ptotic osteocytes within the areas of microdamage, sug-
gesting that these viable cells are the ones responsible for
inducing osteoclastogenesis (218).
It has been shown that osteocytes express markers of
apoptosis in response to withdrawal of estrogen (219), to
oxygen deprivation as occurs during immobilization
(220), and in response to glucocorticoid treatment (221,
222). Increased osteocyte apoptosis was shown to play an
important role in the decreased bone strength observed
with glucocorticoid treatment (223). Further studies have
indicated that dexamethasone treatment of MLO-Y4 os-
teocytes in vitro causes detachment of the cells from the
substrate by interfering with focal adhesion kinase (FAK)
signaling, resulting in cell death (224). Interestingly,
TNF-␣ and IL-1 have both been reported to increase with
estrogen deficiency and also are known inducers of osteo-
cyte apoptosis (225). A number of in vitro studies also
support the concept that the apoptotic osteocyte can sup-
port osteoclast formation. Kogianni et al (208) showed
that apoptotic bodies released by MLO-Y4 cells and pri-
mary osteocytes, but not osteoblasts, supported osteoclast
formation. Other groups have shown that serum-starved
MLO-Y4 cells secrete soluble RANKL (226) and that
damaged MLO-Y4 cell networks embedded in 3-dimen-
sional gels have increased RANKL and decreased OPG
production (227). Recently, thiazolidinediones have been
shown to induce osteocyte apoptosis (228), as does high-
dose alcohol (229) and methotrexate used for cancer treat-
ment (230). Therefore, a major research focus has been on
osteocyte viability and approaches to prevent osteocyte
cell death.
Searches for inhibitors that would protect osteocytes
from apoptosis induced by estrogen deprivation or gluco-
corticoid treatment have identified several candidates.
These include PTH, estrogen, and selective estrogen re-
edrv.endojournals.org 673
ceptor modulators, bisphosphonates, calcitonin, CD40 li-
gand, and calbindin-D28k (for review, see Ref. 231). In-
termittent PTH treatment has been shown to increase
osteocyte density in mice and block osteocyte apoptosis
induced by glucocorticoid treatment (232). Increased os-
teocyte death is also observed after parathyroidectomy in
patients with secondary hyperparathyroidism (233), sug-
gesting a protective role for PTH on osteocytes in vivo.
Estrogen inhibits etoposide-induced apoptosis (234), and
the estrogen receptor is required for the antiapoptotic ef-
fect of mechanical stimulation (235). Mechanical loading
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in the form of fluid flow shear stress was also shown to
protect against glucocorticoid-induced apoptosis through
the release of prostaglandin and subsequent activation of
the Wnt/␤-catenin pathway (171). A target of the Wnt/␤-
catenin pathway, OPG also prevents glucocorticoid-
induced apoptosis (236). Substrate stretching has also
been shown to protect osteocytes from glucocorticoid-in-
duced apoptosis, potentially through activation of FAK,
ERK, and the extracellular matrix-integrin/FAK signaling
that is linked with the Wnt/␤-catenin pathway (237).
Cx43, the major component of gap junctions and hemi-
channels in osteocytes, is also important for osteocyte sur-
vival because Cx43 is required for the antiapoptotic effects
of bisphosphonates (238) and deletion of Cx43 in osteo-
blasts results in animals with increased osteocyte apopto-
sis (239). Bisphosphonate treatment was shown to reduce
osteocyte apoptosis in response to fatigue loading (240)
and to protect against glucocorticoid-induced apoptosis
by transiently increasing ERK phosphorylation (241). A
similar effect was also observed with calcitonin and me-
chanical stimulation (242). Treatment of ovariectomized
mice with a pan-caspase inhibitor, QVDOPh, was shown
to inhibit ovariectomy-induced osteocyte apoptosis and
reduce osteoclastic bone resorption (243). Inhibitors of
osteocyte apoptosis may therefore prove to be useful ther-
apeutics for the treatment of diseases of bone loss.
Although much attention was being focused on osteo-
cyte apoptosis, one group of investigators noted that
the magnitude of glucocorticoid-induced apoptosis in
MLO-Y4 cells was much less than that induced by cyto-
kines such as TNF-␣ and that the same caspase pathways
were not activated (244). They decided to investigate
whether glucocorticoid treatment could be inducing au-
tophagy in these cells (244) and showed that glucocorti-
coid was associated with induction of autophagy-related
markers in osteocytes in vitro and in vivo. Autophagy is a
mechanism in which the cell selectively degrades some of
its own contents in an attempt to maintain viability under
conditions of stress. It is a tightly regulated process of
lysosomal “self-degradation” in which the cell degrades
and recycles nonessential cellular products such as parts of
674 Dallas et al Osteocytes as Endocrine Cells
the cytoplasm and intracellular organelles to reallocate
limited cell resources to processes that are critical for sur-
vival. Autophagy can therefore protect cells from apopto-
sis and eventually cell death, thereby preserving viability
until the stress can be relieved. However, should the stress
continue or worsen, the outcome can be cell death. Other
investigators have also shown glucocorticoid-induced os-
teocyte autophagy in vivo (245), where it was shown that
low-dose glucocorticoid induced autophagy and high-
dose glucocorticoid induced apoptosis. At the most recent
American Society for Bone and Mineral Research meeting,
it was shown that targeted deletion of the autophagy gene,
ATG7, using the Dmp1-Cre driver, which reduced au-
tophagy in osteocytes, resulted in mice with low bone mass
(246). These data suggest that the long-lived osteocyte
requires numerous protective mechanisms, one of which is
the capacity to enter the state of autophagy, at least peri-
odically, to enable it to survive for decades within its en-
closed environment.
IX. Osteocytic Perilacunar Remodeling: An Old
Concept Rediscovered
Bone is a porous tissue. Whereas blood vessels and hav-
ersian canals are obvious porosities, the osteocyte lacunae
are smaller and more numerous, and the canaliculi con-
tribute to bone porosity to an even greater extent. The
surface area of the osteocyte lacunocanalicular system is
estimated to be several orders of magnitude greater than
the bone surface area (247). Osteocytes and their dendritic
processes therefore have access to an extremely large sur-
face area of bone mineral, and the removal of only a few
angstroms of mineral from their lacunar and canalicular
walls would be expected have significant effects on circu-
lating, systemic ion levels. Just as osteoclasts and osteo-
blasts remodel the bone surface, osteocytes may have the
capacity to remodel the surfaces to which they are con-
stantly exposed.
Although exciting new functions of osteocytes have
been discovered within recent years, old functions previ-
ously proposed for osteocytes have also been rediscovered.
One of these old functions is that of osteocytes being able
to remove their perilacunar matrix, a process that was
previously referred to by Belanger et al (248) as “osteo-
cytic osteolysis.” This concept, although proposed in the
1960s, soon disappeared from the literature, most likely
because investigators lacked the tools and technology to
validate the original descriptive observations. Osteocytic
osteolysis was previously viewed as being a feature of
pathological conditions, especially due to high or contin-
uous PTH. Enlarged lacunae have long been described in
Endocrine Reviews, October 2013, 34(5):658 – 690
patients with rickets or osteomalacia (249), uremic osteo-
dystrophy (250, 251), and in response to PTH (252, 253).
An increase in the number of lysosomal vesicles was doc-
umented in response to PTH (71, 248, 254). Enlarged
lacunae have also been described in rats sent into space for
22 days (255), hibernating ground squirrels (256), snakes
(257), and glucocorticoid-treated mice (75). Glycopro-
teins have been detected around the osteocytes of rats
treated with parathyroid extract (258) and in lactating rats
fed with a calcium-free diet (259), and the interpretation
of these data was that the glycoproteins were exposed with
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the removal of mineral.
Interestingly, Wergedal and Baylink (260) had de-
scribed tartrate-resistant acid phosphatase (TRAP) activ-
ity in osteocytes in 1969, which was criticized as poten-
tially being a diffusion artifact from osteoclasts. But this
observation was later validated by Nakano et al (261)
using in situ hybridization for Trap gene expression. After
describing TRAP activity in osteocytes, Baylink went on to
show tetracycline binding to the perilacunar matrix,
which led him to suggest that osteocytes have the ability
not only to remove bone from their perilacunar matrix,
but also to add it back (262). In 1983, Zambonin-Zallone
et al (263) also reported tetracycline labeling in osteocyte
lacunae in egg-laying hens. Although there were numerous
reports of osteocytic osteolysis, there had been few reports
of osteocytes replacing their perilacunar matrix.
Using scanning electron microscopy, gene arrays, and
transgenic technology to examine osteocytes in virgin, lac-
tating, and postlactation mice, it was recently found that
osteocyte lacunar area increases with lactation and returns
to normal with forced weaning (215). Genes thought to be
osteoclast specific, such as Trap and cathepsin K, were
found to be elevated in osteocytes during lactation and
returned to normal with weaning. PTHrP, which is known
to be elevated in the circulation during lactation, repro-
duced these effects on lacunar enlargement, and this effect
of PTHrP was confirmed to be mediated through the
PTH1R. This study shows that healthy osteocytes can
both remove and replace their perilacunar matrix during
processes related to normal reproductive function, sug-
gesting that osteocytes can potentially play a role in min-
eral homeostasis during conditions of high calcium de-
mand, such as lactation. Interestingly, in this study, no
effect on lacunar size was observed in the hind limbs of tail
suspended mice, suggesting that removal of osteocyte peri-
lacunar matrix is not initiated in response to unloading but
is targeted by specific signals, such as hormonal
regulation.
Our work suggests that the osteocyte can not only re-
move its mineralized matrix but also replace this matrix.
We propose that the term “osteocytic osteolysis” be re-
doi: 10.1210/er.2012-1026 edrv.endojournals.org 675

Figure 5. cell cut off from other cells and tissues. How-
ever, the lacunocanalicular system allows for
the flow of canalicular fluid that reflects the
composition of the circulation and exposes the
osteocyte to the hormones and factors that cir-
culate within the blood. A variety of imaging
techniques have demonstrated the connectivity
of osteocyte processes, not only with other
bone cells but also with the vasculature that
permeates the bone matrix (Figure 2, B and C).
Injection of dyes such as procion red into the

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tail vein of a mouse results in the dye being
distributed via the circulation to the osteocyte
lacunocanalicular system within a matter of
minutes, and studies have shown that mole-
cules up to 70 kDa in size can readily reach the
lacunocanalicular space from the bloodstream
(see Section III). Such connectivity between the
canalicular fluid and vasculature allows osteo-
cytes to be exposed to circulating hormones from
distant tissues, but it would also provide a conduit
for the passage of hormones and other molecular
mediators secreted by osteocytes into the circula-
tion to exert effects on distant target organs. Excit-
ing recent research has discovered the presence of
such osteocyte-produced endocrine factors, with
the result that the osteocytic network should now
be viewed as an endocrine tissue that plays a vital
role in the regulation of phosphate homeostasis.
Figure 5. Endocrine signaling by osteocytes. FGF23 secreted by the osteocyte
regulates serum phosphate (Pi) by down-regulating the expression of
Since its identification in 2000, FGF23 has
sodium/phosphate cotransporters in the kidney. There is also a decrease in 1-␣ emerged as one of the most important osteo-
hydroxylase production by the kidney, resulting in decreased NaPi-IIb in the intestine cyte-secreted endocrine factors. Initially iden-
and reduced Pi uptake. High serum FGF23 has also been linked with an increased
tified in the ventrolateral thalamic nucleus of
risk of left ventricular hypertrophy in the heart, atherosclerosis, and vascular
calcification. However, vascular and soft tissue calcification is increased in Fgf23-null the brain (264), FGF23 was found to be most
mouse models, suggesting that FGF23 can promote and inhibit vascular calcification. highly expressed in bone, predominantly by
FGF23 is also known to negatively regulate the secretion of PTH via the parathyroid. the osteocyte (65, 265–267), and highly ele-
vated in conditions of hypophosphatemia.
served for pathological conditions, whereas the term FGF23 is a 32-kDa member of the FGF family
“perilacunar remodeling” be used for the function of the of proteins that binds to FGF receptors (FGFRs). This
healthy osteocyte such as its function in the healthy lac- binding is dependent on the presence of Klotho. It has been
tating animal. It is interesting to see that an old and ap- shown that Klotho can convert the canonical FGFR,
parently forgotten function for osteocytes has now been FGFR1 (IIIc), into a receptor that is specific for FGF23
resurrected and that the observations of early osteocyte (268) and that a monoclonal antibody targeted against
research pioneers have been validated with modern re- Klotho can prevent activation of FGF23 receptor-medi-
search approaches. ated signaling. FGF23 is known to have effects on the
musculoskeletal system, and increased levels of circulating
FGF23 result in hypophosphatemic disorders; however, it
is the effects of osteocyte-secreted FGF23 beyond the bone
X. The Osteocyte as an Endocrine Cell
that are of particular interest here.
It may initially seem counterintuitive to describe the os- One of the most important targets of FGF23 is the kid-
teocyte as an endocrine cell, considering its location deep ney (Figure 5). Signaling between bone and kidney plays a
within the bone matrix and its appearance as an isolated vital role in the maintenance of serum phosphate levels,
676 Dallas et al Osteocytes as Endocrine Cells
which is dependent on the circulating levels of FGF23.
FGF23 has been shown to decrease expression of the so-
dium/phosphate cotransporters NaPi-IIa and NaPi-IIc in
the kidney, which are required for renal phosphate reab-
sorption (269, 270). This leads to increased urinary ex-
cretion of phosphate. Additionally, excess FGF23 levels
are known to down-regulate the expression of 1-␣ hy-
droxylase, which is required for the conversion of 25-hy-
droxyvitamin D to the active vitamin D metabolite, 1,25-
dihydroxyvitamin D [1,25(OH)2D] (265). This reduction
in 1,25(OH)2D levels results in decreased expression of
NaPi-IIb in the intestine, therefore reducing phosphate
absorption and leading to hypophosphatemia (271). This
signaling between the osteocyte and the kidney is bidirec-
tional because 1,25(OH)2D induces expression of FGF23
by the osteocyte in murine (272) and cell culture models
(125, 272), suggesting a negative feedback system.
In addition to 1,25(OH)2D, several other factors have
been shown to modulate FGF23 expression and activity.
For example, intake of dietary phosphorous was shown to
regulate serum FGF23 levels in adult mice, with increased
phosphate supplementation correlating with increases in
serum phosphate and FGF23 levels (273). Likewise, an
increase or decrease in dietary phosphate was shown to
result in increased or decreased levels of circulating intact
FGF23, respectively, in healthy human subjects (274). Re-
cent data have also suggested that PTH may directly reg-
ulate FGF23 levels. Infusion of PTH for 3 days in adult
mice resulted in increased Fgf23 mRNA expression in the
calvaria and increased serum FGF23 (275). PTH was also
shown to up-regulate expression of Fgf23 mRNA in
UMR106 cells, although this effect was abolished if
sclerostin was added to the cultures. In addition, the PKA
activator forskolin up-regulated expression of FGF23 in
these cells, indicating that both the Wnt and PKA pathway
may modulate the effects of PTH on FGF23. Similar re-
sults were observed in a recent study by Rhee et al (276),
in which they generated transgenic mice with constitutive
activation of PTH1R in osteocytes under control of the
Dmp1 promoter. The authors observed increased FGF23
expression specifically in osteocytes, and this effect was
abolished by crossing the mice with mice overexpressing
Sost. In vitro studies showed that treatment with PTH,
PTHrP, and cAMP increased Fgf23 mRNA in osteocyte-
enriched cell cultures, again suggesting the importance of
PKA and Wnt signaling in regulating FGF23.
As mentioned above, PTH secreted by the parathyroid
gland increases FGF23 expression in vivo. Interestingly,
FGF23 is also able to act reciprocally on the parathyroid
gland to decrease PTH secretion, identifying the parathyroid
gland as another endocrine target of osteocyte signaling. Ad-
dition of recombinant FGF23 to cultured bovine parathyroid
Endocrine Reviews, October 2013, 34(5):658 – 690
cells resulted in decreased PTH mRNA expression and re-
duced the secretion of PTH into the culture media (277).
Similar effects were observed in ex vivo rat parathyroid
glands, where recombinant FGF23 decreased Pth mRNA
expression and secretion of PTH into the media and in vivo,
where FGF23 decreased serum PTH levels and Pth mRNA ex-
pression in the parathyroid (278). Increased expression of the
FGF23 coreceptor Klotho was also observed in the parathyroid
in response to FGF23 administration (278).
Recent studies have linked raised levels of circulating
FGF23 to an increased risk of heart disease. Elevated levels of
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FGF23 were found to be independently associated with left
ventricular hypertrophy in human population studies (279,
280). FGF23 also induced hypertrophy in cultured mouse
cardiomyocytes, and injection of FGF23 into wild-type mice
resulted in left ventricular hypertrophy (280). Interestingly,
these effects were found to be Klotho-independent. Increased
serum FGF23 has also been linked with impaired vascular
function (279), vascular calcification (281), and increased fat
mass (282), indicating the importance of osteocyte-regulated
proteins in health and disease (as discussed in Section XII).
These findings of altered cardiac and vascular function also
identify these tissues as target organs of osteocyte-secreted
FGF23.
As discussed previously, the osteocyte is known to ex-
press several other factors that play a role in the regulation
of phosphate homeostasis. DMP1, PHEX, and MEPE
have well-characterized effects on the skeletal system, as
demonstrated by loss of function mutations and knockout
mouse models (65, 91, 283, 284). These secreted proteins
coordinately regulate FGF23 expression and activity and,
by doing so, influence tissues outside of the bone envi-
ronment. DMP1 is a negative regulator of FGF23 ex-
pression because osteocytes in the Dmp1-null mouse
express high amounts of FGF23 mRNA and protein,
compared to wild-type mice, resulting in elevated serum
FGF23 levels (65, 266).
In addition to DMP1, PHEX is also known to inhibit
FGF23. Given that the PHEX protein is an enzyme with
endopeptidase activity, it was suspected that FGF23 could
be proteolytically cleaved by PHEX. However, evidence
has so far suggested that FGF23 is not a direct substrate for
PHEX, but PHEX instead regulates Fgf23 at the transcrip-
tional level (284). The exact mechanism(s) by which
DMP1 and PHEX regulate FGF23 are yet to be deter-
mined; however, recent research has suggested that their
inhibitory effects are mediated by FGFR signaling (285).
Dmp1-null and Hyp mouse models show evidence of en-
hanced FGFR signaling compared to wild-type control
mice, and the elevated levels of FGF23 present in the bone
marrow stromal cells from both mouse models were abol-
ished by inhibition of FGFR signaling.
doi: 10.1210/er.2012-1026
The effects of MEPE on FGF23 and matrix mineral-
ization are dependent on its cleavage to release an acidic
serine aspartate-rich MEPE-associated motif (ASARM)
from its C terminus. This 19-amino acid ASARM peptide
is known to be a potent inhibitor of mineralization in vivo
(94, 286), and Mepe-null mice are characterized by pro-
gressive increases in trabecular bone mass and mineral
apposition rate with aging (287). Again, the exact mech-
anisms by which MEPE and the MEPE-ASARM peptide
regulate phosphate homeostasis are still to be elucidated;
however, the ASARM peptide is known to bind specifi-
cally to PHEX in vitro (288) and inhibit PHEX enzymatic
activity (93), which results in up-regulation of FGF23 ex-
pression. PHEX can also regulate FGF23 by binding to
MEPE and preventing its proteolytic degradation and the
release of the ASARM peptide (288, 289). In addition, the
phosphorylated MEPE-ASARM peptide itself is a sub-
strate for PHEX, with cleavage of ASARM by PHEX neu-
tralizing its activity and restoring mineralization (95).
The effects of MEPE can also extend beyond the bone
and may operate independently of FGF23. MEPE is pres-
ent in the serum of adult humans, suggesting an endocrine
function for MEPE, and the levels of MEPE correlate with
serum phosphate levels (290). Administration of full-
length MEPE into a rat model was shown to directly de-
crease uptake of phosphate in the proximal tubule and
lead to renal phosphate wasting (291). Likewise, admin-
istration of recombinant MEPE to renal cell cultures in-
hibited phosphate uptake (291), and short-term infusion
of MEPE in rats inhibited renal and intestinal phosphate
absorption independently of serum FGF23, PTH, or
1,25(OH)2D (292). In addition to the full-length protein,
the MEPE-ASARM peptide has also been shown to inhibit
phosphate uptake in vivo (293). MEPE-ASARM is ele-
vated in the serum of Hyp mice and was found to accu-
mulate in the proximal tubules in the Hyp mouse kidney
(294). Overexpression of MEPE in a transgenic mouse
model was also shown to decrease renal calcification and
increase blood vessel formation in the kidney (295), al-
though MEPE expression in this model was also increased
in the proximal tubules, so the effects cannot be defini-
tively attributed to osteocyte-derived MEPE. It is clear that
interactions between FGF23, PHEX, MEPE, DMP1, and
other SIBLING family members are essential for regulat-
ing phosphate levels; however, further studies are required
to fully elucidate how the interplay between these proteins
occurs at the genetic and molecular level.
XI. Crosstalk Between Osteocytes
and Muscle Cells
As discussed above, osteocytes can signal to tissues other
than bone via secretion of FGF23. One of these targets of
edrv.endojournals.org 677
pathological FGF23 signaling is cardiac muscle, with in-
creases in FGF23 resulting in left ventricular hypertrophy.
This therefore raises an interesting possibility; can osteo-
cytes directly influence muscle mass by secreting muscle
regulatory factors? Such interplay between bone and mus-
cle seems highly plausible, especially because muscle and
bone mass are tightly correlated throughout life. During
organogenesis, muscle and bone develop in close associ-
ation from common mesodermal precursors. During ex-
ercise and disuse, changes in muscle and bone mass are
also closely coupled, and with aging there is a concomitant
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loss of both bone and muscle mass. The dogma has been
that the major effect of muscle on bone is mediated
through mechanical loading of bone via muscle contrac-
tion during exercise and locomotion. However, it has re-
cently been proposed that muscle, in addition to the skel-
eton, can act as an endocrine tissue to secrete factors into
the circulation that target other tissues. Like osteocytes,
muscle is also a source of circulating signaling factors,
termed “myokines” (296, 297). These myokines include
factors such as IGF-I, IL-6, IL-8, IL-15, leukemia inhibi-
tory factor, FGF21, and follistatin-like 1 (298). Pedersen
(297) has proposed that skeletal muscle, the largest organ
in the body, is an endocrine organ that exerts effects on
other organs.
Previous studies have also demonstrated that skeletal
muscle can secrete factors such as IGF-I, FGF2, and myo-
statin, which can influence osteoblast activity and differ-
entiation (299, 300). However, whether direct signaling
occurs between muscle and osteocytes was unknown. Re-
cently, several studies have suggested that such signaling
may indeed play an important physiological role in osteo-
cytes in processes such as regulation of cell viability and
response to mechanical stimuli. Jähn et al (301) found that
differentiated C2C12 myotubes and primary muscle se-
crete factors that protect osteocytes against apoptosis due
to glucocorticoids and that muscle contraction enhanced
factor production. The muscle-secreted factor inhibited
glucocorticoid-induced apoptosis through activation of
the Wnt/␤-catenin pathway. Lara et al (302) found that
differentiated myotubes and primary muscle produce a
factor that synergizes with fluid flow shear stress to in-
crease prostaglandin production by osteocytes. Again, this
was likely mediated through synergistic activation of the
Wnt/␤-catenin pathway (302). Conversely, MLO-Y4 os-
teocyte-like cells and primary osteocytes secrete factors
that induce muscle myogenesis in C2C12 pluripotent cells,
and these factors activate the Wnt/␤-catenin pathway
(303). These findings suggest that this pathway plays a
role not only in muscle development but also in muscle
repair and myogenesis. Two factors produced by osteo-
cytes, PGE2 and Wnt3a, were found to enhance myogen-
678 Dallas et al Osteocytes as Endocrine Cells
esis. These early studies provide supporting data that cross
talk occurs between muscle and bone and suggest other
potential endocrine and/or paracrine functions for osteo-
cytes, but they will require further in vivo validation.
XII. Role of Osteocytes in Disease
The importance of osteocytes in maintaining bone health
has been demonstrated by the diseases that occur in their
absence. A 34% reduction in osteocyte density was ob-
served in cancellous bone of the iliac crest in patients who
presented with fracture when compared to healthy con-
trols, suggesting that osteocytes are important in preserv-
ing the mechanical properties of bone. These patients did
not show an increase in the number of empty lacunae,
however, suggesting that the decrease in osteocyte number
was not due to osteocyte apoptosis but was due to a lower
rate of osteocyte formation (305). A decrease in endothe-
lial NOS and neural NOS expression was also observed in
the femoral neck of hip fracture patients, in comparison to
nonfracture controls (306, 307). This is likely to result in
a reduction of NO, a powerful anabolic stimulator (as
previously discussed), potentially leading to bone fragility.
Apoptosis of osteocytes is commonly observed in pa-
tients with steroid- and alcohol-induced osteonecrosis of
the femoral neck (221, 308). Osteocyte death is also ob-
served after renal transplant, possibly due to the admin-
istration of glucocorticoids and other immunosuppressive
therapeutics (309). There has recently been concern over
the possibility that therapeutic use of bisphosphonates
may result in osteonecrosis of the jaw. This has been linked
to an increase in osteocyte apoptosis in humans (310). In
support of this, in a rat experimental model, the admin-
istration of zoledronic acid resulted in osteocyte cell death
(311). However, opposing results were observed in mice,
with zoledronic acid having no effect on osteocyte viability
in the mandible and femur (312).
Abnormalities in osteocyte morphology have been
noted in many musculoskeletal diseases. In osteoporotic
bone, disruption of the orientation of the lacunocanalicu-
lar system is observed, with decreased connectivity be-
tween neighboring osteocytes. Osteoarthritic bone is char-
acterized by a decrease in osteocyte connectivity; however,
the orientation of the processes is unchanged. In contrast,
osteocytes in osteomalacic bone display high connectivity
but with disorientation of the dendrites (59). Such disrup-
tion of the lacunocanalicular system will affect osteocyte
signaling, likely leading to alterations in the bone mechan-
ical properties.
Hyperparathyroidism has a profound effect on the skel-
etal system. Excessive PTH secretion results in a loss of
Endocrine Reviews, October 2013, 34(5):658 – 690
bone mass due to increased osteoclast activity (313).
RANKL has been shown to be an important mediator of
this increase in osteoclast activity, which could be atten-
uated in a mouse model of secondary hyperparathyroid-
ism by treatment with the endogenous RANKL inhibitor
OPG (314). With recent studies suggesting that osteocytes
are a major source of RANKL and OPG in vivo (112, 113),
it seems likely that the detrimental effects on bone health
observed in hyperparathyroidism are mediated, at least
partly, by the osteocyte. In contrast to the effects of con-
tinuous PTH, intermittent PTH treatment is known to be
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anabolic and may be partially mediated through down-
regulation of osteocyte-expressed sclerostin (315–317). In
humans, it has been reported that patients administered
PTH have reduced sclerostin levels (317), and serum
sclerostin levels in postmenopausal women negatively cor-
relate with PTH (318). Overexpression of Sost in a mouse
model attenuated the anabolic effects of intermittent PTH
administration (316). However, these animals still
showed a response indicating that the anabolic effect can-
not be fully attributed to sclerostin regulation. Sclerostin
itself has become a very attractive target for therapeutics
to increase bone mass. Monoclonal antibodies have been
created to target sclerostin, and their efficacy has been
tested in both animal and clinical trials. Sclerostin anti-
body was shown to protect against bone loss due to hind
limb immobilization in a rat model (107), and it also in-
creased bone formation and mineral density in cynomol-
gus monkey (319) and rat models (320, 321). In a recently
published human trial, a single treatment with sclerostin
antibody increased the expression of bone formation
markers such as alkaline phosphatase, decreased markers
of bone resorption, and led to gains of up to 5.3 and 2.8%
in bone mineral density in the vertebrae and hip, respec-
tively (106). Sclerostin antibody has also shown therapeu-
tic promise in the treatment of fractures (105) and has
alleviated the loss of bone observed after dexamethasone
treatment of young mice (322). Off-target effects appear
to be minimal, with the only reported issue being a de-
crease in platelet count and increased megakaryocytes in
sclerostin antibody-treated rats. These effects were spe-
cies-specific, with no reactivity between the antibodies and
human or monkey platelets or megakaryocytes (323).
As discussed in Section X, the effects of osteocyte sig-
naling are not merely confined to the bone microenviron-
ment but can involve other tissues such as the kidney and
the cardiovascular system. FGF23 expression is known to
be regulated by DMP1, PHEX, and MEPE, which are all
predominantly expressed by osteocytes. Elevated levels of
circulating FGF23 lead to increased renal phosphate ex-
cretion and subsequent hypophosphatemia and osteoma-
lacia (270, 324). In chronic kidney disease, serum levels of
doi: 10.1210/er.2012-1026
FGF23 are increased, particularly in the later stages of the
disease (325, 326). Treatment with FGF23 antibody re-
stored serum phosphate levels in the Hyp mouse model
and corrected the osteomalacic phenotype (327). Like-
wise, treatment of Dmp1-null mice with FGF23 antibody
ameliorated the bone defects observed in these mice by
increasing levels of circulating phosphate (38). In addition
to effects on the musculoskeletal system, high serum
FGF23 levels have been linked with atherosclerosis (328),
ventricular hypertrophy (329, 330), increased risk of car-
diovascular disease (331), and vascular calcification
(281). Treatments targeting FGF23 would therefore ap-
pear to offer significant therapeutic potential and not
merely for bone homeostasis.
Decreased bone mass is a common feature in inflam-
matory bowel disorders, particularly in children (332,
333), and it was recently reported that the bone loss ob-
served in Crohn’s disease was associated with increased
osteocyte death and decreased bone remodeling (334).
The role of osteocytes in cancer-induced bone disease
has, so far, been relatively unexplored. However, it was
discovered recently that there is an increase in osteocyte
apoptosis, and subsequently a decrease in viable osteo-
cytes, in the bones of patients suffering from multiple my-
eloma (335). This resulted in an increase in osteoclast for-
mation and osteolytic lesions. A recent study has also
suggested that circulating levels of sclerostin are elevated
in patients suffering from multiple myeloma and correlate
with decreased bone mass (336). Other Wnt signaling in-
hibitors secreted by osteocytes, such as DKK1 and SFRP1,
are also known to be involved in myeloma-induced bone
destruction (86, 164). The importance of the osteocyte as
a source of these factors in multiple myeloma, however,
remains to be determined.
XIII. Summary and Perspective
It is becoming clear that the osteocyte is a far more active
and functional cell than dogma has previously suggested.
Recent research has further proved many of the suspected
functions of osteocytes, such as mechanosensation and
regulation of bone remodeling, in addition to suggesting
novel functions, such as the ability to act as an endocrine
organ. The potential of the osteocyte to influence cells and
tissues far beyond the bone microenvironment suggests
that we may only be “scratching the surface” of what the
osteocyte is capable of. Signaling between osteocytes and
the parathyroid, kidney, cardiac and skeletal muscle in-
dicates the importance of the endocrine function of osteo-
cytes and the impact that maintaining osteocyte viability
edrv.endojournals.org 679
may have on other tissues. It also raises the question of
which other cells and tissues could be communicating with
the osteocyte. The extensive connectivity of the lacuno-
canalicular system with the vasculature permits the trans-
mission of signals to and from osteocytes from tissues
throughout the body, and it is highly likely that other
targets of osteocyte signaling will be discovered in the near
future.
The osteocyte is gaining increasing interest as a target
of therapeutics to increase bone mass. Clinical and animal
trials have shown that using monoclonal antibodies di-
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rected against sclerostin has a potent bone anabolic effect.
Future research may yield additional osteocyte secreted
factors, which may have therapeutic potential in disorders
such as sarcopenia and chronic kidney failure, given the
cross talk between these organs. Clearly, the osteocyte
must now be considered not only in the context of its
immediate microenvironment but also in its far-reaching
endocrine effects beyond the bone—therefore, adding to a
growing list of functions of these fascinating, dynamic
cells.
Acknowledgments
Address all correspondence and requests for reprints to: Lynda F. Bone-
wald, PhD, Department of Oral and Craniofacial Sciences, School of
Dentistry, University of Missouri-Kansas City, 650 East 25th Street,
Kansas City, Missouri 64108. E-mail: Bonewaldl@umkc.edu.
This work was supported by grants from the National Institutes of
Health (PO1 AR46798 and PO1 AG039355 to L.F.B. and R21
AR054449, RO1 ARO51517, and S10 RR027668 to S.L.D.).
Disclosure Summary: The authors have nothing to disclose.
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